Olivia Stoddart RN, BSN, CPTC Case Study Region 5 Collaborative Fall 2017 Olivia Stoddart RN, BSN, CPTC

Demographics 24 y/o Male Found pulseless and apneic – unknown downtime ROSC after 15 min of CPR, epi x 3, and defib x 1 Multiple previous admissions for drug related issues Tox screen positive for benzos, opiates, amphetamines, and THC.

Admission Course 11:30 – Presented to the ED areflexic MD pre-mentions donation to family in ED Family positive towards donation – make pt a DNR 14:00 – Hospital notifies Lifesharing 15:10 – Lifesharing onsite for initial evaluation 17:00 – CBFS findings consistent with brain death 21:00 – Family asking to speak with Lifesharing authorize for donation (pt was not registered) blood sent for serologies Pt officially declared BD by two MDs on the following day

PHS Increased Risk Previous admissions make mention of pt with IVDA Family confirms on DRAI (Donor Risk Assessment Interview) that pt was using needles Needles used day prior to admission No track marks identified on physical assessment Lifesharing indicates pt as PHS increased risk on UNET Note placed in donor highlights stating pts specific behaviors of IVDA

Donor Management – Day 1 Pts BP and HR very labile → on T4 using pressors/vasodilators as needed Vent settings: PRVC 100% FiO2 PEEP 12 → started APRV → Q1H PEEP Metabolic acidosis with pH 7.18 → started bicarb gtt Oliguric with admit Cr 1.94, peak 2.3 LFTs elevated In DI → started vaso gtt and free water flushes to lower Na Insulin gtt for glucose > 200 WBCs increasing – on 3 abx

Donor Management – Day 2 All labs start to trend in the right direction TEE shows EF 69% with no abnormalities HR and BP still labile CT abd normal, CT chest shows patchy opacities in BLL ABGs improving, but not perfect ABO and serologies result: blood group B, +CMV IgG Decision made to give donor 1 more day to work up organs Allocate in the morning to have best chance at placing all organs

Allocation – Day 3 Heart: 3 recipients a 3 centers declined due to PHS increased risk Lung: 6 recipients at 2 centers declined due to PHS increased risk Liver: no declines due to PHS increased risk K/P: 4 recipients at 4 centers declined due to PHS increased risk Kidney: 2 recipients at 2 centers declined due to PHS increased risk Research: 1 program declined to back up organs due to PHS increased risk Able to get regional acceptance for all organs

OR – Day 4 Heart declined in OR Was able to re-allocate heart in OR to lung recipient who was listed for both heart and lung. Upon arrival of K/P team, recipient called and changed mind, now declining PHS increased risk organs Was able to re-allocate K/P intra-op to another regional center

Outcome Heart/Lung transplanted in 48 F Liver transplanted in 57 F K/P transplanted in 45 M Kidney transplanted in 56 F

Best Practices Clear and accurate communication of PHS increased risk behaviors Will attempt to complete DRAI with family/friend who knows the donor the best Will complete multiple DRAIs if necessary If donor will be PHS increased risk due to hemodilution of sample, will re-send blood for serologies once pt is no longer hemodiluted Any behaviors that don’t meet PHS increased risk criteria, but are of interest, will be listed in the donor highlights

THANK YOU!